Healthcare Provider Details

I. General information

NPI: 1861431447
Provider Name (Legal Business Name): JORGE TONY CISNEROS M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7056 MARINER BLVD
SPRING HILL FL
34609-1000
US

IV. Provider business mailing address

9921 CYPRESS SHADOW AVE
TAMPA FL
33647-1857
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-5557
  • Fax: 352-597-0552
Mailing address:
  • Phone: 813-972-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME69642
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: